From:___________________________

I think my grade in your course,___________________, should be
changed from ______ to _______ for the following reasons
(please tick the appropriate reasons):


___1. The persons who copied my paper made a higher grade than I did.


___2. The person whose paper I copied made a higher grade than I did.


___3. This course will lower my Grade Point Average and I won't get
into:

______Law School
______Graduate School
______Medical School
______My Fraternity/Sorority
______Dental School
______Tri County Tech
______The Mickey Mouse Club
______Other


___4. I have to get an A in this course to balance the F in
_______________.

___5. I'll lose my scholarship.

___6. I'm on a varsity sports team and my tutor couldn't find a
copy of your exam.

___7. I didn't come to class and the person whose notes I used
did not cover the material asked for on the exam.

___8. I studied the basic principles and the exam wanted every
little fact.


___9. I learned all the facts and definitions but your exams
asked about general principles.


__10. You are prejudiced against:

______Males
______Jews
______Blacks
______Females
______Catholics
______Whites
______Protestants
______Moslems
______Minorities
______Chicanos
______People
______Students


__11. If I flunk out of school my father will disinherit me or at
least cut my allowance.


__12. I was unable to do well in this course because of the
following illness:

______mono
______broken baby finger
______acute alcoholism
______pregnancy
______VD
______fatherhood


__13. You told us to be creative but you didn't tell us exactly
how you wanted that done.


__14. I was creative and you said I was just shooting the bull.


__15. I don't have a reason; I just want a higher grade.


__16. The lectures were:

______too detailed to pick out important points
______not explained in sufficient detail
______too boring
______all jokes and not enough material
______all of the above


__17. This course was:

______too early, I was not awake.
______at lunchtime, I was hungry
______too late, I was tired


__18. My (dog, cat, gerbil) (ate, wet on, threw up on) my
(book, notes, paper) for this course.


__19. Other___________________________________________________

[Acknowledgement: This form is based on (well, stolen from...) a version on Howard A. Levine's webpage.]